Health inspection·January 20, 2026

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure resident equipment was maintained for two (R3, R4) of five residents reviewed for safe/clean/homelike in the sample of five.The findings include:1 R3's admission Record shows he was admitted to the facility on [DATE] with diagnoses including chronic respiratory failures, venous insufficiency, lymphedema, morbid obesity, fluid overload, cellulitis of right lower limb, bed confinement status, and stage 4 pressure injury of the sacral region.R3 Minimum Data Set (MDS) dated [DATE], shows that he is cognitively intact.On January 20, 2026 at 10:54 AM, R3 said the right siderail on his bed is loose. R3 moved the right siderail and it moved side to side. R3 said he let the facility know about it about a week ago, and they haven't fixed it yet. R3 said he needs to use his side rails in order to roll from side to side. On January 20, 2026 at 11:15 AM, V7 Maintenance Director said the facility does not use work orders. If a resident needs something fixed, receptionist or staff will get ahold of maintenance and tell them. V7 said the facility does not keep track of when something was requested and when it was repaired/completed. V7 said he was aware that R3's side rail was loose and said that R3's side rail was on the list of things to work on. V7 said he was told about the loose side rail late yesterday (January 19, 2026).2 R4's admission Record shows he was admitted to the facility on [DATE] with diagnoses including type II diabetes mellitus, chronic kidney disease, anemia, restless legs syndrome, adjustment insomnia, glaucoma, and acquired absence of right leg blow knee.R4's MDS dated [DATE], shows he is cognitively intact.On January 20, 2026 at 10:40 AM, R4 said he has been waiting for maintenance to fix the right arm rest on his wheelchair. R4 said he was waiting for a shorter armrest. R4 said it is too long and R4 scratched his right forearm on the metal of the armrest because he uses his arms to propel the wheelchair. R4's right arm rest on his wheelchair had a cushioned piece. The cushioned piece was hanging off the back about 5-6 inches. There was metal underneath the cushioned piece. R4 had a scrape on his right forearm. The left armrest did not have the cushioned piece. R4 said he reported this concern a couple of weeks ago. On January 20, 2026 at 11:15 AM, V7 Maintenance Director said there was nothing wrong with R4's armrest. V7 said that R4 wanted a shorter arm rest to match the left armrest. V7 said he is waiting for a replacement arm rest. V7 said he received R4's concern about a week ago. The facility's Preventative Maintenance Program Policy dated January 2025 shows, Purpose: To conduct regular environmental tours/safety audits to identify areas of concern within the facility. Preventative Maintenance Program will review the following areas during random rounds: Resident equipment is in working order. Bed rails are in working condition. Page 1 of 3 145234 145234 01/20/2026 Pearl Pointe Nursing Rehab & Care 900 South Kiwanis Drive Freeport, IL 61032

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure serving temperatures were logged to ensure food was served at a palatable temperature. This failure has the potential to affect 64 residents residing in the facility. The findings include:The facility's Data Sheet dated January 20, 2025 shows 65 residents were residing in the facility. Per V9 Corporate staff, there is one resident that does not eat food from the facility kitchen.On January 20, 2026 at 8:40 AM, the kitchen food temperature logs were requested and reviewed. The food temperature logs showed no food temperatures were taken on January 8, 2026 for all three meals, January 9-11, 2026 for breakfast and lunch meals, January 12, 2026 for supper, January 13, 2026 for all three meals, January 14, 2026 for breakfast and lunch, January 15, 2026 for all three meals, and January 16,17, 2026 for breakfast and lunch. Both cooking temperatures and serving temperatures were missing and not documented. On January 20, 2026 at 9:10 AM, R2 said that the food is always cold when it is served. At 10:40 AM, R4 said the food is not good. R4 says he orders out often because the food is bad. R4 says the food is cold most of the time. R4 says it depends on when he gets his food as to how hot or how cold it is. At 10:54 AM, R3 said there are some good meals and some meals not so good. R3 said his hot food is served cold at times. On January 20, 2026 at 8:40 AM, V4 Dietary Manager said food temperatures should be taken when they are cooked and then right before they are served to ensure they are at the right temperature. V4 said staff should log the temperatures as they are taken. V4 said that food trays are delivered via an opened metal cart with a cloth covering over it. V4 said the facility does not utilize heated place and no closed cart. V4 said the facility does not use any heating apparatus to keep food warm while they are being delivered to residents. V4 said those would be helpful to keep the food warm. The facility's Resident Council Minutes dated October 3, 2025 shows, Dietary old business: Resident Council members wanted to keep the old business regarding the cold food. They also stated the coffee is cold at times and they don't always get condiments on their meal trays. Resident Council Minutes dated December 3, 2025 shows, Dietary Old Business: Resident Council members wanted to keep the old business regarding the cold food. They also stated the coffee is cold at times and they don't always get condiments on their meal trays. Residents Affected - Many 145234 Page 2 of 3 145234 01/20/2026 Pearl Pointe Nursing Rehab & Care 900 South Kiwanis Drive Freeport, IL 61032

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on interview and record review the facility failed to ensure final cooking temperatures were logged to ensure food was cooked to a food-safe temperature before serving. This failure has the potential to affect 64 residents residing in the facility. The findings include:The facility's Data Sheet dated January 20, 2025 shows 65 residents were residing in the facility. Per V9 Corporate staff, there is one resident who does not eat food from the facility kitchen.On January 20, 2026 at 8:40 AM, the kitchen food temperature logs were requested and reviewed. The food temperature logs showed no food temperatures were taken on January 8, 2026 for all three meals, January 9-11, 2026 for breakfast and lunch meals, January 12, 2026 for supper, January 13, 2026 for all three meals, January 14, 2026 for breakfast and lunch, January 15, 2026 for all three meals, and January 16,17, 2026 for breakfast and lunch. Both cooking temperatures and serving temperatures were missing and not documented. On January 20, 2026 at 8:40 AM, V4 Dietary Manager said that food temperatures should be taken when food is done cooking, and then the temperature should be taken again right before serving the food. V4 said temperatures should be logged as they are taken. The facility's Food Safety and Sanitation: General Preparation and Cooking Practices policy revise September 18, 2023 shows, Policy: The facility will follow sanitary practices in food preparation and cooking to keep food safe. Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby prevent foodborne illness. Hot food prepped for serving will maintain a minimum temperature of greater than or equal to 135 degrees Fahrenheit when on the steam table and prior to being served to the residents. If the food is below 135 degrees Fahrenheit, the staff must reheat the food to 165 degrees Fahrenheit to assure time and temperature control. 145234 Page 3 of 3